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Employee Benefit Questionnaire USTSV-EBPQ - California
| Employee Benefit Questionnaire Form. This is a California form and can be used in US Trustee USBC Central Federal . |
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U.S. Department of Justice United States Trustees Central District of California 411 W. Fourth St Suite 9041 Santa Ana, CA 92701 (714) 338-3400 FAX (714) 338-3421 725 South Figueroa St. Suite 2600 Los Angeles, CA 90017 (213) 894-6811 FAX (213) 894-2603 3685 Main St. Suite 300 Riverside, CA 92501 (909) 276-6990 FAX (909) 276-6973 21051 Warner Center Lane Suite 115 Woodland Hills, CA 91367 (818) 716-8800 FAX (818) 716-1576 Debtor: EIN: Is this a public corporation? 1. Employer maintains a Yes Bankruptcy Case # group health No . If No, go to #2. pension plan If the debtor sponsors a group health or dental plan, complete the information below. Yes employee contributions Yes employee contributions Premiums paid through Are the premium payments current? Benefits paid from employer contributions No general assets of the company Name, address and telephone number of responsible officer: 2. If the debtor sponsors a pension plan, complete the information below. Yes ___ . If No, go to #3. 401(k) Plan Money Purchase Plan Profit Sharing Plan Employee Stock Ownership Plan Defined Benefit Plan Name, address and telephone number of responsible officer: Does the employee make contributions to the plan? Have all employee contributions been forwarded to the trust fund? Yes Yes No No If the debtor maintains a defined benefit or money purchase plan, are they fully funded? Have any trustees, officers, owners or board members of the debtor received any distributions form the plan within the last year? If so, please provide the name, address and title for each individual: Have any trustees, officers, owners or board members received any loans from the plan that are not participant loans? If so, please provide the name, address and title for each individual: Has the debtor company received any loans from the plan? If so, please state the approximate date, amount and purpose of the loan. 3. I declare under penalty of perjury that the answers contained in the foregoing question are true and correct to the best of my knowledge. By: Dated Revised December 2011 A copy of this document will be provided to the Department of Labor USTSV-EBPQ
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